Anthem insurance plan with MaineHealth under review

GARDINER, Maine — A proposed deal between two heavy hitters in Maine’s health care market to offer insurance next year is raising concerns that patients may have to travel further for care and to find new doctors. The deal could affect tens of thousands of residents and greatly shape the rollout of President Barack Obama’s health reform law in Maine.

MaineHealth, the parent organization of Maine Medical Center in Portland, and health insurer Anthem Blue Cross and Blue Shield plan to offer a new insurance product on Maine’s health insurance exchange, an online market where consumers and small businesses can shop for coverage beginning in October 2013. The plans would take effect in January 2014. The exchanges are a key component of the reform law, which aims to widen coverage to 30 million people.

A Friday public hearing hosted by the Maine Bureau of Insurance addressed the network of hospitals and doctors that would provide care to customers who buy the Anthem-MaineHealth plans, which would be available to individuals who buy their own insurance, small businesses and the uninsured.

Workers who have health insurance through a large employer aren’t eligible to shop for plans on the exchange and wouldn’t be affected by the Anthem-MaineHealth deal.

The plans include 32 of Maine’s 38 hospitals, but exclude Central Maine Healthcare, which operates Central Maine Medical Center in Lewiston, Bridgton Hospital and Rumford Hospital, as well as Parkview Adventist Medical Center in Brunswick, York Hospital, and Portland’s Mercy Hospital.

Central Maine Healthcare officials have denounced the plan as a “backroom deal” that allows MaineHealth to undercut hospitals that compete with its health system, undermining the intent of the reform law to improve access to affordable health care. Central Maine Healthcare filed a lawsuit earlier this month to make Anthem’s application public before the insurance bureau decides whether to approve the plan. It also launched a website dedicated to defeating the deal, stopanthemsbackroomdeal.com.

Brenda Weeks, 54, of Auburn, has held an individual Anthem policy for 29 years. She’s worked hard to assemble a team of CMMC medical providers who treat her for multiple sclerosis, and now fears losing them, she said.

Weeks, who uses a wheelchair and relies on a ventilator to breathe, said she’s overwhelmed by the prospect of having to find new doctors and a different hospital, as well as a new health plan with unknown costs and coverage.

“I’ve been very loyal to them, “ she said of Anthem, which also insured Weeks through her parents when she was young. “I don’t like the idea that they are going to turn my world upside down, and that’s what will happen if I have to make these changes.”

Chuck Gill, a spokesman for Central Maine Healthcare, said Friday’s hearing has led to further confusion about which doctors are included in the network, after discrepancies in Anthem’s list were discovered.

“It’s got everyone asking more questions that we didn’t expect and not getting lots of answers,” he said by phone, stepping away from the hearing.

Anthem and MaineHealth contend that their collaboration will lead to lower health insurance premiums for consumers. The hospitals included in the network agreed to significantly reduced payments from Anthem in exchange for having more patients funneled to their facilities. Anthem has said those rate reductions are critical in offsetting extra costs associated with the Affordable Care Act, which requires insurers to offer a wider scope of benefits and prohibits them from denying customers with preexisting medical conditions.

MaineHealth serves much of southern and western Maine, with nine member hospitals and affiliate hospitals in Augusta, Brunswick and Lewiston.

Magnifying the effect of the move by Anthem and MaineHealth is the fact that the only other option on Maine’s exchange next year will be plans offered by a small startup nonprofit, Maine Community Health Options. The plans must be reviewed by the insurance bureau by July 31 and win approval from federal regulators.

About 257,000 Mainers are expected to be eligible to shop for insurance on Maine’s exchange, which will be run by the federal government. Yet, the insurance exchange won’t be their only option for health insurance coverage, and companies can still sell policies off the exchange.

Some of the 33,000 individuals who buy their own insurance may stick with another insurer, Mega Life, which will still sell policies in Maine but not through the exchange. Similarly, many of the 91,000 people who have coverage through a small business could continue getting coverage from several insurers that plan to stay in Maine’s market but not sell policies on the exchange. The third group eligible to shop on the exchange, Maine’s 133,000 uninsured, are more likely to do so, but could choose to remain without coverage, become eligible for Medicaid, or find a way to afford an off-exchange plan.

Both Anthem and Maine Community Health Options are interested in offering plans both on and off the exchange. Plans sold off the exchange wouldn’t be eligible for federal subsidies.

The Anthem-MaineHealth plans would affect not only future Anthem customers, but also existing customers. Anthem has requested permission from the insurance bureau to cancel or stop renewing its “nongrandfathered” individual and small group policies and replace them with the new “narrow network” policies.

Colin McHugh, who leads Anthem’s contracting efforts with health providers in the region, said the narrow network would still allow policyholders plenty of choice in who they see for care, according to his written testimony. All of the state’s northern hospitals and at least one hospital in every southern Maine county (except Sagadahoc, which doesn’t have a hospital) will be included, he said.

“The more focused network is still broad, offering members significant choices in high-quality hospitals, primary care physicians and specialists,” his testimony read.

Patients could still visit any hospital for emergency care, according to McHugh.

Anthem has stressed that its proposal with MaineHealth remains in the early stages.

Jud Knox, president of York Hospital, said his facility’s exclusion from the network will force Anthem patients to sever ties with their preferred medical providers unless they pay out of pocket.

“Almost all of these Anthem subscribers will not be able to afford that,” he said, according to his written testimony. “As a result, these patients will have to discontinue treatment with their primary care providers and discontinue treatment with their customary treating specialists. They will have to decide whether they should forego or postpone treatment, or travel a considerable distance to a new hospital, [primary care physician], or specialist.”

Mercy CEO Eileen Skinner raised similar concerns about Portland-area patients covered by Anthem, and questioned whether Maine Medical Center could handle an influx of tens of thousands of Anthem patients who would have to abandon the excluded hospitals and turn to MMC for care.

“It is still unclear to me how the network was developed and what criteria were used by Anthem to select participating network providers,” Skinner said, according to her written testimony. “Mercy is a longstanding, low-cost, high-quality Anthem participating provider, yet Mercy was never approached by Anthem with a proposal to join the network.”

A number of insurance carriers nationally have turned to narrow network plans, contending that limiting network size allows them to offer plans with better quality or more efficient doctors and hospitals, which could dampen spending or improve care.

The hospitals excluded from the Anthem network complained that the company failed to take into account hospital cost and quality criteria, which insurers in other states have relied on in devising narrow network plans.

Health insurers in Maine aren’t required to contract with every hospital, but must provide “reasonable access to services.”

Central Maine Healthcare spokesman Gill also previously criticized the move by Anthem and MaineHealth as an affront to taxpayers. The exchanges will offer federal subsidies to qualifying working families to help them afford insurance. Anthem may be a private company, but the products it sells on Maine’s exchange will be partially financed by taxpayers, Gill has said.

While the provider network has garnered the most attention, it’s just one element in determining whether health insurance under Obamacare will lead to better and less expensive coverage in Maine. No information about how much the exchange plans will cost or specifics about the benefits they’ll include has been released yet publicly. That information, which will affect patients beyond western and southern Maine, is expected later this summer.

The insurance bureau will accept written comments from the public about the Anthem-MaineHealth provider network through next Friday.